Indications for Clinical Nutrition Types
How to Decide What Type of Clinical Nutrition Support to Use
When nutritionally-at-risk patients are not able to gain sufficient nutrient intake from hospital food, fortified hospital food or diet, enteral nutrition (EN), including oral nutritional supplements or tube feeding via nasogastric, nasoenteral or percutaneous tubes, may be required to achieve clinical nutrition requirements.1
If EN intake is determined to be insufficient, parenteral nutrition (PN) should be started as a supplement to, or replacement for enteral tube feeding in order to avoid disease-related malnutrition.2,3
It is important to note that nutritional support is not restricted to the exclusive administration of EN or PN, but PN and EN may complement each other, e.g. with the use of PN plus minimal “trophic” enteral feeding or EN plus supplemental PN.4
The following chart illustrates the determination of nutrition support:
Administration of PN is usually reserved for situations in which no other way of providing nutrients is possible. The risks and benefits of EN versus PN must always be carefully balanced, e.g. after major surgery or during critical illness.
When Is EN Indicated?
The rule of thumb states that if the gut works, EN is indicated. In patients with a functioning gastrointestinal (GI) tract, EN is ideally started within 24 to 48 hours of intensive care unit (ICU) admission.5,6,7,8,9,10
When Is PN Indicated?
When patients have a non-functional, inaccessible or perforated gastrointestinal (GI) tract, PN is recommended. Moreover, if patients cannot be fed adequately and/or safely via the oral/enteral route, PN is indicated.2,11
When Is supplemental PN Indicated?
In this approach, PN supplies only part of daily nutritional requirements, which supplement EN intake. Patients receiving less than their targeted enteral feeding after two to three days should be considered for supplemental PN to fill the caloric gap.10
When Is Total PN Indicated?
In cases where EN is not tolerated, total PN can supply patients with all of their daily nutritional requirements. This form of nutrition is generally delivered by a central venous catheter.7
The Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that if there is evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible.9
- 1. Lochs H, Allison SP, Meier R et al. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, definitions and general topics. Clin Nutr 2006;25(2):180-186.
- 2. a. b. National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guidelines, No. 32 London 2006.
- 3. Kreymann KG. Early nutrition support in critical care: A European perspective. Curr Opin Clin Nutr Metab Care 2008;11:156-159.
- 4. Heidegger CP, Berger MM, Graf S et al. Optimization of energy provision with supplemental parenteral nutrition in critically ill patients: a randomized controlled clinical trial. Lancet 2013;381(9864):385-393
- 5. Heyland DK. Parenteral nutrition in the critically-ill patient: More harm than good? Proc Nutr Soc 2000;59:457-466.
- 6. Heyland DK, Dhaliwal R, Drover JW et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN 2003;27:355-373.
- 7. a. b. Gramlich L, Kichian K, Pinilla J et al. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004;20:843-848.
- 8. Rubinsky MD, Clark AP. Early enteral nutrition in critically ill patients. Dimens Crit Care Nurs 2012;31:267-274.
- 9. a. b. McClave SA, Martindale RG, Vanek VW et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN 2009;33:277-316.
- 10. a. b. Singer P, Berger MM, Van den Berghe G et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009;28(4):387-400.
- 11. Rothaermel S, Bischoff SC, Bockenheimer-Lucius G et al. Ethical and legal points of view in parenteral nutrition - guidelines on parenteral nutrition chapter 12. Ger Med Sci 2009;7:Doc16.